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#841
26.09.2006, 23:06
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Странноватая картина для перитонита с периодически усиливающимися болями, пусть даже лейкоцитоз вырос за прошедшие сутки. По делу лежать должна женщина с таким диагнозом, а не боятся повторного приступа.
Как водится у хирургов если не аппендицит, то аднексит. Но влагалищно или ректально надо бы "глянуть"!! Вот тут у меня "свой" гинеколог подсказывает ,что при воспалительных процессах в придатках возможны схваткообразные боли. 
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#842
27.09.2006, 01:26
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Цитата:
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#844
27.09.2006, 18:56
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The correct answer is B. The patient's history of intermittent, unilateral pelvic pain that is associated with nausea during peak pain is classic for ovarian torsion. Although torsion has been reported in normal size ovaries, this will occur most often with an ovarian cyst approximately 5-6 centimeters in size. When the ovary has twisted and its blood supply is cut off, the patient experiences extreme pain and nausea. When it untwists, the symptoms remit. The patient's white blood cell count will often be mildly elevated. This diagnosis requires a high index of suspicion, a careful pelvic examination by the physician, and a low threshold to order a pelvic ultrasound. The presence of arterial flow to the ovary does not rule out this diagnosis as twisting of the ovary occurs intermittently. Laparoscopic ovarian cystectomy or oophorectomy is the treatment of choice.
The presence of rebound tenderness and guarding (choice A) are more often associated with a perforated viscus (ruptured ectopic pregnancy, ruptured appendix, perforated ulcer, hemoperitoneum). Isolated tenderness at McBurney's point implies the presence of appendicitis (choice C). Although appendicitis can present nonspecifically with vague symptoms, the patient's cyclic waves of pain and nausea are more classic for ovarian torsion. A normal pelvic exam is a rare possibility, but not typical for ovarian torsion (choice D). Vaginal bleeding (choice E) is not associated with ovarian torsion, but may be a feature seen with ectopic pregnancy. This presentation is also a concern for an ectopic pregnancy, but the urine pregnancy test was normal.
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#845
27.09.2006, 19:00
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A 34-year-old woman comes to the clinic because of left lower quadrant pain for the last 4 months. The pain is intermittent and seems to worsen during her periods. She has no significant past medical history and does not take any medications. She is sexually active with 1 partner and they use condoms for birth control. She has never been pregnant and has regular menstrual periods. Her last menstrual period was 17 days ago. Physical examination and vital signs are normal. Pelvic examination reveals mild tenderness in the mid and left side of the pelvis. There is no vaginal discharge or bleeding and the cervical os is closed. The most appropriate next step is to
A. order a CT scan of the pelvis B. order ultrasonography of the pelvis C. prescribe nonsteroidal antiinflammatory medications for menstrual cramps D. prescribe oral contraceptives E. schedule a diagnostic laparoscopy
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#849
28.09.2006, 23:28
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The correct answer is B. The most likely cause of this patient's left sided pelvic pain is ovarian cysts. A follicular cyst occurs when the normal follicle does not shrink after the release of the egg. Follicular cysts are soft, have thin membrane walls, and contain clear fluid. They can rupture, causing sudden, severe pain that gradually goes away over several days. Usually, however, they spontaneously disappear over the course of 1 or more menstrual cycles. They can cause changes in periods and pelvic pain. Depending on the size of the cyst, it can just be observed for spontaneous resolution or treated with oral contraceptive pills. The best way to confirm the diagnosis of ovarian cysts is by ultrasonography of the pelvis.
A CT of the pelvis (choice A) is not the best way to image the ovaries or to confirm the diagnosis of ovarian cysts. A CT does not provide the resolution that ultrasonography does to evaluate the cyst in fine detail in order to ensure that it is a simple cyst as opposed to a more worrisome complex cyst. Prescribing nonsteroidal antiinflammatory medications for menstrual cramps (choice C) is not appropriate in the management of this patient. She has had symptoms of intermittent pelvic pain for the last 4 months which makes menstrual cramps as the etiology of pain, less likely. It is important to further evaluate the pelvis for a cause of her symptoms and confirm the diagnosis of ovarian cysts. It is also important to rule out neoplastic causes of pain such as a cystadenoma or cystadenocarcinoma. Prescribing oral contraceptive pills (choice D) is a reasonable option once the diagnosis of an ovarian cyst is made. However, it is important to make the diagnosis first with ultrasonography of the pelvis. If the cyst appears simple on ultrasonography and is 4 cm or less in size, it can be followed with serial ultrasonography for resolution. For simple uncomplicated ovarian cysts in the premenopausal period, treatment with the administration of high-dose monophasic oral contraceptive pills (>35 mcg estradiol) is recommended after consultation with a gynecologist to normalize cycles and to facilitate reduction in cyst size. Diagnostic laparoscopy (choice E) allows direct visualization of the intraperitoneal contents including the ovaries which can add diagnostic yield. Surgical intervention and/or excision of relevant pathology may be accomplished by this method. This procedure is not the next appropriate step in the management of this patient. Ultrasonography of the pelvis usually provides sufficient information to make the diagnosis of simple uncomplicated ovarian cysts, without the need for direct visualization of the pelvic organs.
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#850
28.09.2006, 23:29
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You care for a 32-year-old school teacher who is in the second half of her pregnancy. A 6-year-old boy came to class on the first day of school with "an infection with 'slapped cheeks' and a lace-like rash." His mother told your patient that the boy became sick with a high fever, muscle aches, and a headache 10 days before school started. When these symptoms subsided, this rash suddenly appeared 1 day ago. A doctor examined the boy and told the mother that all of his "blood work" was normal. Since this boy did not want to miss the first day of classes and he "felt fine" his mother allowed him to attend school. Even though your patient is asymptomatic, she is worried about her health and the health of her unborn baby. The best next step is to
A. administer intravenous immunoglobulin therapy to prevent infection B. advise her to have an amniocentesis to evaluate the unborn baby's health C. advise her to stay home from school until the boy's rash disappears D. ask her to return for reexamination in 1 week E. reassure her of the relatively low potential risk to her and her unborn baby
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#851
29.09.2006, 06:04
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Мальчик, перенесший инфекционную эритему, уже не заразен.
E. reassure her of the relatively low potential risk to her and her unborn baby
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#852
29.09.2006, 20:03
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Мне тоже кажется. что Е - особенно потому, что идет уже вторая половина беременности
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#853
29.09.2006, 21:59
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Да, Е. Можно было бы внести среди вариантов ответов пункт о проведении серологических тестов
 , однако ребенок действительно уже не заразен.
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#854
29.09.2006, 22:11
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The correct answer is E. The boy in this patient's class has the classic symptoms of erythema infectiosum (Fifth disease), which is an infection caused by Parvovirus B19. Patients with this disease are only infectious before the onset of the rash, during the period with the nonspecific febrile illness. The virus typically only causes a significant, severe illness in individuals with sickle cell disease and other hemoglobinopathies. In rare cases, parvovirus contracted during pregnancy has been associated with fetal hydrops and death. But as stated earlier, the boy in this pregnant patient's class was contagious before school started, and since he is no longer contagious, she should be reassured of the relatively low potential risk to her and her unborn baby. If she was in contact with him during the phase of the illness before the onset of the rash, she should have serologic testing and a fetal ultrasound to evaluate the health of her and the baby. It should be mentioned that the complications of parvovirus in pregnant women typically occur during the first half of pregnancy.
It is inappropriate to administer intravenous immunoglobulin therapy to prevent infection (choice A) because the boy that this patient was in contact with, was most likely no longer contagious. Intravenous immunoglobulin therapy is given to immunocompromised patients with chronic parvovirus infection. Supportive care is all that is indicated for patients with a typical parvovirus B19 infection. The patient in this case does not require any preventive treatment. Since this patient was not exposed to the boy in the contagious phase of the disease, it is inappropriate to advise her to have an amniocentesis to evaluate the unborn baby's health (choice B). Also, since the greatest risk to the unborn baby is during the first half of the pregnancy, she should be reassured of the low risk of complications. It is incorrect to advise her to stay home from school until the boy's rash disappears (choice C) because the boy in her class in no longer infectious. It is unnecessary to ask her to return for reexamination in 1 week (choice D) because the boy in her class is no longer contagious and so it is unlikely that she will develop symptoms. However, it is appropriate to advise her to come back to the office if she does develop any symptoms.
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#855
29.09.2006, 22:14
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A 87-year-old man with a long-standing history of smoking, chronic obstructive lung disease, peripheral vascular disease, and multiinfarct dementia is admitted to the hospital under your care for gangrenous involvement of the second and fourth toe of his right foot. An arteriogram shows that revascularization is not feasible. After extensive evaluation the surgeon recommends amputation below the knee. The patient is alert and oriented to person, place, and situation. He has some in short-term memory deficits and higher cognitive functions seem intact. You and the surgeon explain the situation to the patient, and despite his dementia, you both believe that he adequately understands the risks and benefits of the surgery. Another physician and nurse also witness the consent procedure and believe that the patient has full comprehension of the risks and benefits of the surgical procedure. However, the patient's son, who is the designated proxy in the patient's power of attorney health care documents, adamantly opposes any surgical intervention. He points out that the patient has indicated in the document that he would not like any aggressive measures to save his life. Despite detailed discussions and several family meetings, the son remains adamant about refraining from any surgical intervention. The most appropriate action is to
A. arrange for a psychiatry referral to assess patient's competency B. ask the son to find other physicians to care for his father C. consult your hospital attorney D. discharge the patient form hospital E. proceed with a below-the-knee amputation
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Линейный вид
